Information Collection

Request For Medicare Payment

IC 177153 under ICR 198509-3220-009 · OMB 3220-0131.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0131 can be found here:

Documents and Forms

Document Name Document Type

No indexed documents/forms are available for this IC yet. A refresh has been queued.

Information Collection (IC) Details

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IC Title:	REQUEST FOR MEDICARE PAYMENT	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	G-740S	No	No
Form	G-740B	No	No
Form	HCFA-1500	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,100,000	940,750	6,159,250
Annual IC Time Burden (Hours)	938,400	79,465	858,935
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.